CLM-2026-023856
Meadow Skin Care Associates, Dermatology. Service 2026-09-11 at office (POS 11). Received 2026-10-09.
Member
Resolved through the identity graph
- Member
- Diego Wood
- Member ID
- UHC-94499-61
- Date of birth
- 1998-05-03
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-417129
- Relationship
- Child, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-0233
- Coverage period
- 2024-09-01 to 2026-05-07
- Deductible
- $701.67 of $1,000.0070%
- Out-of-pocket maximum
- $1,046.56 of $4,000.0026%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 5570109764
- Network
- In network
- Rendering NPI
- 5060610107
- Location
- Miami, FL · TIN 98-6447059
- Authorisation / referral
- none / REF470382
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 17110 | Destruction of benign lesions, up to 14 | — | 1 | 1 | $286.00 | $177.32 | — | — | DeniedCO27 |
| Totals | $286.00 | $177.32 | — | — | ||||||
- 1. D22.5 Melanocytic nevi of trunkprincipal
- 2. L30.9 Dermatitis, unspecified
- Patient account
- PA-444229
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-040053 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-11 is after coverage terminated on 2026-05-07. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 28 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Meadow Skin Care Associates (5570109764). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Meadow Skin Care Associates2026-09-11 11:56
Patient seen for melanocytic nevi of trunk.
- SystemSystem: Claims system2026-10-09 00:41
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-10-09 09:05
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-09-11 is after coverage terminated on 2026-05-07.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024778 | 2026-08-29 | Evergreen Diagnostic Imaging | $1,220.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.